Please fill out the below patient registration form or download a copy here and bring it with you to your first appointment.
Date of Birth
Ref Number next to name
Level of Cover
UninsuredHospital CoverExtras Cover Only
Private Health Fund Name
Private Health Fund Membership Number
---NilGold CardWhite Card
DVA Card Number
DVA White Card Approved Condition
Referring Doctor’s Name
GP Name (if not referrer)
Do you wish to receive appointment reminders via SMS?
To enable the ongoing provision of care within this practice, and in keeping with the Privacy Act 1988 and Australian Privacy Principles (APPs), we wish to provide you with information on how your personal and health information may be used or disclosed.
WestsideENT collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs.
Your personal and health information will only be used for the purposes for which it is collected, or as otherwise permitted by law.
I consent to the use of my personal and health information by WestsideENT and other health providers involved in my medical care. I consent to the disclosure of my personal and health information by WestsideENT to other health providers directly or indirectly involved in my personal health care or medical treatment.
I give my consent to WestsideENT to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information, to WestsideENT as may be requested.
Yes, I give my consent
Medical Conditions (Please tick all that apply)
High Blood Pressure
Cardiac Bypass Surgery
Blood Clots / Pulmonary Embolism / DVT
Chronic lung disease/COPD
Do you have a history of any bleeding diseases?
Is there a family history of any bleeding diseases?
eg neurofen, brufen, celebrex, voltaren
-- Please Choose --Current SmokerNon SmokerFormer Smoker
No of years smoking
No of cigarette per day
Do you drink alcohol?
Drinks per week